Healthcare Provider Details

I. General information

NPI: 1669209938
Provider Name (Legal Business Name): PRO DENTAL MI 1 PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16201 FORD RD STE 115
DEARBORN MI
48126-2876
US

IV. Provider business mailing address

10 WOODBRIDGE CENTER DR STE 520
WOODBRIDGE NJ
07095-1152
US

V. Phone/Fax

Practice location:
  • Phone: 313-451-8304
  • Fax: 313-789-7993
Mailing address:
  • Phone: 732-731-8398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SIMONE WILSON-ADELEKE
Title or Position: DIRECTOR OF CREDENTIALING
Credential: MPA-PPA
Phone: 732-731-8398